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■ Waste Tire Si ey & Inspection Repon -Ispection Report Number <br /> calRecycle State of California — <br /> CalRecycle 181(Rev.10110) S1 I6�/®y ®r� Page `' 1 1226590 <br /> Dept.of Resources Recycling and Recovery(CalRecycle) u r Y�s <br /> BLUE OR BLACK INK PEN <br /> Part A-Survey <br /> Business Profile Inspection Details <br /> TPID- Inspection h m © Inspection Type(Fill one) <br /> Site Suffix: 7 b 0 Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local �` 1 / If Referral,choose referral type(Fill one) <br /> Identifier: Sc n J13 t4111 Wfl 0 CHP 0 CalRecycle 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name Inspected By Inspector <br /> l - � <br /> Physical ddress b <br /> a L4t <br /> CA Js33� Inspection Date . I 0 <br /> man��c� Time In Time Out <br /> Business Rep Title ] C 10 AM ®AM <br /> j QPM I I 5 O QPM <br /> f A'lit? o wnLr <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> ID Active ® Passenger 0 Generator 9 Outdoor <br /> O 0 Closed 0 Altered <br /> ��� Latitude 0 Hauler ® Indoor <br /> O 0 Inactive 0 Truck <br /> Longitude - 0 Planned 0 OTR 0 End-Use 0 Container <br /> Business Type(Fill a!I t`r:' ,-)p'y <br /> ® New Tire Dealer 0 Auto P-r. 'r 0 Trucking Fleet 0 Government 0 Retreader 0 Dismantler 0 Tire Derived Fuel <br /> IS Used Tire Dealer 0 Auto E-r•:�y 0 Car Dealer 0 Collection 0 Crumb Rubber <br /> 0 Service Station 0 Hauler 0 Agriculture 0 Shredder 0 Other <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V I A I HAULING AND MANIFEST REQUIREMENTS <br /> 0 Notice Of Violation 0 Extension <br /> 0 O <br /> PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> 0 0 PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> PRC§42956-Registrati.ry Decal in Vehicle <br /> 0 0 14 CCR§18459-Responsible Entities Complying with Manifesting Requirements Date m / m / m <br /> 0 0 14 CCR§18459.1 -Tire Program ID Number from CalRecycle <br /> 0 0 14 CCR§18459.2.1 -SL,-<nittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXT) h <br /> 0 0 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years o <br /> 0 0 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers 0 Referred/CalRecycle Enforcement <br /> 2 <br /> Lu <br /> 0 0 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> 0 0 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators ®In Compliance-No Violations o <br /> 0 0 Other:§ <br /> Comments fLUlA� 11F� WG �IIC.1�} 1 Ull It 1� �- O L ll <br /> Inspection Form Included: 0 <br /> Comments Included: ® <br /> mess R 's Signatur Phone Nu^bAr Inspect 's Signature Phone Number <br /> INSTRUCTIONS ON BACK orrect:0 Incorrect: EXAMPLE 1 2 3 62081 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LEA <br />